SURGICAL CURE OF CANCER
'of the GASTRO - INTES-
TINAL CANAL

-BY-

William J. Mayo, M. D.

ROCHESTER, MINN.

FROM

THE ST. PAUL MEDICAL JOURNAL

January, 1910.

\

[Reprinted from The St. Paul Medical Journal, January, 1910.]

By William J. Mayo, M. D., Surgeon to St. Mary's Hospital,

ROCHESTER, MINNESOTA.

The cancer problem is the most important which confronts
mankind, and while we are perhaps no nearer its final solution
so far as knowledge of its direct cause is concerned, recent in-
vestigation has at least cleared away some of the fog of supposi-
tion and superstition which has surrounded the subject in the past.

All forms of animal life are liable to some form of cancer,
and the statements made by travelers that aboriginal races do
not suffer from the disease, is based upon inference and incorrect
observation. The health margin of primitive people is very nar-
row and the victims of cancer among them succumb quickly in
the struggle for existence. The disease therefore, is but little in
evidence rather than absent.’

It has been definitely shown also that cancer is not hereditary
although it cannot be said positively that the soil in certain fam-
ilies is not more favorable to its development than it is in others.
The presumptive evidence is against direct contagion by inocu-
lation although the Scoth verdict of “not proven” best describes
the present status of our knowledge.

During the last ten years an enormous impetus has been
given to the study of cancer, by the foundation of research labor-
atories. In this country they have been endowed by private
philanthrophy, as in Boston, or through state aid as in Buffalo,
New York, In England the active work is represented by the
Imperial Cancer Commission and the Middlesex Hospital. The
latter institution is to be associated with a third cancer institute
to be carried out by the Barnato Fund. In Germany the Heidel-
burg Cancer Institute under the charge of Czerny, is the most
notable.

These various institutions for cancer research have been
vastly useful not only in clearing away venerable cancer legends,
but in that they have accentuated certain previously known clinical
facts which had not been recognized at their full value.

♦Annual Address, Kentucky State Medical Society, Oct. 19, 1909.

It is worth while to consider thjs bearing of several of these
investigations upon the radical treatment of cancerous disease

First : Joiian Orti-i and others h'ave shown that all there

is of cancer is in the cancer cell, that each cell contains within it-
self the possibility of unlimited cell division, and that the stroma
of the cancer which was for a long time considered a necessary
part of the cancerous process, was in truth, but the measure of
nature’s resistance, and represented an ineffectual effort to stem
the tide of cancerous invasion. Viewed from this standpoint we
can readily see why scirrhus is slow in its development, and why
contracting cancer of the mamma in which the stroma is so
greatly in excess of the cell, may by slow strangulation maintain
an efficient barrier against the disease for many years. It also
explains the action of various chemical and thermic agents which
have proven useful in the palliation and in checking the spread of
the cancerous process. While the individual affected by the dis-
ease may not be able to effectually resent the insult of cancer
growth which in him is represented by a high-cell proliferation
with a small amount of stroma, yet his tissues will quickly resent
the insult of a burn, and the resulting, scar tissue acts as a barrier
which like the stroma of the slower growths temporarily prevents
its spread.

Second'. What might be called the triumph of modern in-
vestigation is the proof that all dancers are at one time local and
that in this period they are curable. This fact should lead us to
strive more earnestly for a recognition of the early manifesta-
tions and the eradication of the disease in its curable period. That
form of skepticism which urges that all cancers are primarily
constitutional has been the cause of enormous loss of life. For-
tunately this will no longer serve to excuse ignorance or inefficient
methods of diagnosis, and it is well for us to understand too, our
moral responsibility for unnecessary delay. The practitioner of
the future who procrastinates while watching the growth of a
tumor, will be held accountable to the general public and he can
no longer shelter himself behind venerable but exploded theories.
Finally, it leads to the conclusion that there is no known cure for
cancer except removal while it is still a local process, and that
all cancers in all parts of the body are necessarily surgical from
their inception, and that a suspicion of it should lead to a surgical
consultation.

Third : Heideniiain was one of the first to correctly ap-

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predate the relation of the lymphatics to the spread of cancer, and
his paintaking research work in cancer of the breast, still remains
a monument to his name. He made from 11,000 to 17,000 serial
microscopic sections from eleven breasts, practically converting
the whole field into one gigantic microscopic picture, and demon-
strated for all time the manner in which cancer spreads through
the lymphatics. The more recent investigations, particularly
those by Handley of the Middlesex Hospital, have served to
accentuate and extend Heiden haines views.

It has been shown that the older the patient the slower the
development of the cancerous process. The reason for this was
pointed out some years ago by C. H. Mayo. In a study of the
lymphatics he demonstrated that the lymphatic system reached
its height in adolescence and that in advancing life the lymphatics
underwent a progressive atrophy, and this lack of lymphatics ac-
counted for the benign course of the disease in the latter decades
of life as contrasted with the riotous spread of the malignant
process in the young.

The practical bearing of our modern understanding of the
relations of the lymphatics to cancer, have already borne fruit and
sounded the death knell of the caustic and paste in the eradication
of the disease. Admitting that these agents 'do in a way remove
the local focus, of what avail are they against the lymphatic
spread. Modern operations which include a wide area about the
local source, and removal of the tributary lymphatics, have en-
abled Halsted and others, by special technic, to give 50 per cent
of five year cures in cancer of the breast, as against 14 per cent
of the older writers with their limited local operations. Wertheim
shows 51 per cent of 5 year cures in cancer of the cervix as
against eight per cent of the older surgeons.

Fourth : Bashford, in his address on cancer before the

International Medical Congress, 1909, again calls attention to the
remarkable influence of chronic irritation on breaking down local
resistance and thereby permitting cancer invasion ; a clinical ob-
servation which has heretofore been about our only known fact
in its etiology. The chronic irritation factor is evidenced in many
ways, for example: The lip cancer of the smoker and its pre-

ponderance in the male. The betal nut chewer of both sexes and
cancer of the mouth. Gallstones in the production of cancer of
the gallbladder. Ulcer of the stomach and its relation to gastric *
cancer. The “chimney sweep” cancer, and many others too

— 4 —

numerous to mention. All of this leading up to the most im-
portant point in prophylaxis — the avoidance of the sources of
chronic irritation and the relief of such conditions when present,
as they can be truly said to be a precarious condition awaiting
only the unknown factor to set loose normal limitations upon cell
reproduction. In this connection Keen has pointed out the
necessity of a careful watch for evidence of degeneration in
moles, warts, nevi and congenital defects of all kinds, on account
of the frequency of secondary cancer.

As a result of our modern conception of the cancer process,
there has been an enormous gain in the percentage of cures
following operations upon (accessible organs, the lip, breast,
uterus, etc., where the diagnosis can be made early by direct in-
spection and palpation, but 75 per cent of all cancers in the male
and 50 per cent in the female involve the alimentary canal and
are not readily accessible to these direct methods of examina-
tion. It is true that by means of the esophagascope the esophagus
can be inspected, and the rectum can be palpated digitally and in-
spected through the proctoscope, but one-half of all carcinomata
in the male, and a somewhat smaller percentage in the female,
lie between the cardiac orifice of the stomach and the beginning
of the rectum, and therefore cannot be subjected to direct in-
spection and palpation. By means of the gastroscope, glimpses
of the interior of the stomach may be obtained, and the lower
sigmoid may be somewhat more adequately inspected by means of
the sigmoidoscope. The X-ray bismuth method is 'also being
used and is proving of modest service in the diagnosis of gastro-
intestinal disease, yet after all these means of diagnosis are of
secondary value only.

It may be truthfully said that the diagnosis of malignancy
of the gastrointestinal tract including the bilary apparatus and
the pancreas, is uncertain and often impossible during the stage
of local involvement because we cannot directly examine the parts
involved, and we have no test which will reliably show the dis-
ease by examinations of the blood or secretions. Crile, Elsbury
and others are, however, doing research work on hemolysis which
promises well although as yet in the experimental stage.

As could be expected from the advanced stage in which
malignant disease of the alimentary canal has heretofore come to
operation, the results of surgical treatment have been bad. Bill-
roth's mortality after resection of the stomach was 64 per cent,

— 5 —

yet the medical mortality was and still is, ioo per cent. As a
result of these various influences the curious aromaly is still seen,
i. e. the patient suffering from cancer of the stomdch is consider-
ed a medical case and is admitted to the medical wards of hos-
pitals where he has no chance for his life whatever. There is no
more reason why cancer of the stomach should be considered a
medical disease than that cancer of the lip, breast or uterus should
be considered medically.

To what extent is this pessimism as to the curability of
cancer of the gastro-intestinal tract justified by experience? Are
the bad results due to fundamental causes and therefore unavoid-
able, or are cancers in this region similar in all respects to cancers
in other parts of the body, and the unfavorable results due to the
lateness of the diagnosis and operation ? I think there can be no
question but that the latter view is the correct one.

With your permission I will confine my remarks to actual re-
sults obtained in St. Mary’s Hospital with patients operated on
by Dr. C. H. Mayo and myself during the last ten years, from
October i, 1899 to October 1, 1909. During this period 251 gas-
tric resections were made for cancer with a mortality of 13 per
cent. Of these patients 29 per cent operated upon more than
three years ago who recovered from the operation are alive and
well. Two have passed the five year period and one six and one
half years.

No other organ in the body is involved in cancer as often as
the stomach. Thirty per cent of all cancers in the male involve
the stomach. Twenty-two per cent involve the stomach in the
female. These statistics are conservative. Some estimates show
a much higher percentage, even as high as 50 per cent.

Graham has shown that 59 Per cent of the cases of gastric
cancer which came to us, gave a clear history of chronic ulcer.
From the microscopical examination of the resected portion of
the stomach, Wilson was able to demonstrate the development
of cancer on ulcer in 51 per cent of the specimens obtained from
gastrectomies. As accounting for this somewhat higher percent-
age of gastric cancer in men over women, it has been shown in
our series that 58 per cent of true gastric ulcers were in the male
sex.

This question of cancer development on ulcer is a mooted
point and is opposed by a number of men who have devoted a
great deal of time to the purely non-operative treatment of dis-

eases of the stomach. Their convictions are, I believe, the result
of fallacious clinical examinations, and so far as this subject is
concerned, the equally fallacious results of post mortem examina-
tions. How is it possible to determine from the examination of
a patient dead from cancer of the stomach whether or not ulcer
had existed. By the time the patient is dead of the disease all
evidence would be lost in the extent of the cancer process.

At the present time we have a considerable number of favor-
able cases in which resection of the stomach for ulcer shows
early cancerous development on its margin. This brings up the
important point that when the chronic ulcer of the stomach calls
for surgical treatment, resection of the diseased area is a wiser
procedure than gastroenterostomy, and leads us to believe that
many of the cases in which cancer has followed upon ulcer with-
in two or three years after gostroenterostomy, that the cancer was
probably present in its earlier stages at the time of the primary
operation.

As Deaver points out, what is needed is an earlier diagnosis
of cancer of the stomach, and he says most pertinently, that the
greatest source of delay is the test meal, and that prolonged and
useless laboratory investigation is responsible for the hopeless
condition in which so many of the patients present themselves to
the surgeon. Without going into the question of the value of
the test meal, and various laboratory tests, I think from a practi-
cal standpoint that Deaver is right. Every year we subject about
3500 individuals to gastric examination with analysis of the
stomach contents, and about ten per cent of these patients come
to operation. Gastric analysis and the test meal are of importance
but not of great diagnostic value. They are valuable just as the
temperature and pulse are valuable, but they do not carry with
them conclusive evidence during the curable period. They are
merely adjuncts to the clinical side, and prolonged delay on
account of their supposed value is to be depreciated.

There are two diagnostic factors of great surgical import
within the reach of every physician, and a proper recognition of
their value will bring surgical cure to a vast multitude of patients
afflicted with cancer of the stomach. Early cancer of the stomach
does not give evidence of its presence per se but only as it inter-
feres mechanically with gastric function. First and most import-
ant by obstruction, the early presence of which is fortunate for

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the victim requiring as it does an early surgical investigation.
Second, by tumor.

Cancer of the body of the stomach is ushered in by a long
train of indefinite symptoms, the lateness of the appearance of
obstruction and tumor usually precluding the possibility of surgi-
cal cure. On the contrary early obstruction and early tumor
indicate not only a favorable condition, but that the growth is
in the pyloric end, the removable part of the stomach.

It has been stated by some authority, now happily forgotten,
that the presence of tumor in the stomach proved the condition to
be hopeless. Quite the contrary is true. The appearance early
in the disease of a movable tumor with or without obstruction,
promptly gives a diagnosis and makes surgical relief possible
in a high percentage of cases. I will not insult your intelligence
by calling attention to the fact that the ability to feel a tumor is
not confined to the gastric specialist, and certainly the diagnosis
of a mechanical obstruction is simple in the extreme. The patient
is told to take a full meal in the evening including with it some
raisins and half cooked rice. Any residue in the stomach is re-
moved in the morning with the stomach tube and if food remnants
are repeatedly shown, the diagnosis of mechanical obstruction is
established. It is obiected that some of the obstructions are due
to ulcer. Quite true, but such obstructions are equally incurable
by medical means.

In our series of cases cancer of the small intestine occurred
13 times. Of these five were of the duodenum and could not be
subjected to operation beyond the exploration necessary to estab-
lish their presence. Two involved the jejunum at its origin and
were inoperable, and six originated in various parts of the je-
junum and ileum, all of which were resected.

It is evident that the small intestine, perhaps because of its
freedom from sources of chronic irritation, is not often the pri-
mary seat of cancer. In two of the patients the neoplasms began
upon the polypoid growth, again illustrating the baneful influence
of chronic irritation. Resection with removal of the tributary
lymphatics is of course indicated.

Fortunately the limited caliber of the small intestines calls
early attention to the growth by obstructive symptoms, while the
situation in the abdomen gives an opportunity for palpation in
the discovery of the tumor.

We have resected the large intestine 69 times for carcinoma.

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Of these 28 were of the cecum and ascending colon. Nine of the
transverse colon and flexures, 32 of the sigmoid and descending
colon. Sixty per cent, of our patients subjected to resection more
than three years ago and who recovered from the operation
are alive and well ; several of them have passed the five year
period.

Cancer of the large intestine clearly illustrates the pernicious
influences of which I have spoken previously. The colonic con-
tents are mechanically more irritating than the small intestine as
the injesta is more solid in character as well as more prolonged
in residence. Fortunately cancer of the large intestine is among
the most curable to which the human being is subject. It has a
very limited lymphatic connection ; not only are the glands sparse
but slow to take offense. This is rendered necessary by the very
nature of its function and even when enlarged glands are found
they are often the result of the accompanying infection without
actual invasion of the cancerous cells. Not only this, but its
lymphatics lie in well recognized groups and are capable of sur-
gical removal.

In conclusion I wish to call attention to cancer of the gall-
bladder as an illustration of the fact that cancer is primarily
a local condition and curable by surgical operation in that stage,
and again because it illustrates the perniciousness of chronic
irritation of gallstones in its production.

Of the 3084 cases of gallstone disease which we have operat-
ed upon, in no less than 74, nearly three per cent, cancer involved
the gallbladder and biliary tract, and in every case in which we
were able to ascertain the facts, gallstones were present. In eight
cases the gallbladder and a considerable portion of the liver were
removed for a known cancer process. None of. these patients
lived a year but in five instances the removal of a thickened,
functionless “gallbladder containing stones, in which cancer was
not suspected, the microscopical examination of the removed gall-
bladder showed early cancer. All but one of these patients are
alive and well.

In summing up it can be shown conclusively, I think, that
there is no reason why operations for cancer of the gastroin-
testinal canal should not show results as good, both immediate
and remote, as after operations for cancer in any other part of
the body.

i

*■

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